Case Study

The Biotech Dragon

A Kid-Friendly Approach to Self-Regulation

Magazine Issue
July/August 2019
Case Study

Among the most common questions I get from parents whose kids come to see me in therapy is, How can I help my child calm down? For a long time, I could only offer the same well-worn solutions—cognitive behavior workbooks, exercises to help identify different emotions, and talk therapy—most of which aren’t particularly effective for young children. 

Much of the time, I found these methods simply didn’t stick. The kids I worked with weren’t interested in doing exercises from a book, had difficulty understanding them, or couldn’t recall them at difficult moments. As a therapist and clinical researcher, with nearly 15 years of experience working with emotionally dysregulated children in numerous healthcare settings, I’ve long looked outside the therapy field for fresh approaches. After all, there are plenty of innovative strategies to teach kids other skills, like reading, math, and music. Why not adapt these strategies for self-regulation?

One strategy—bioresponsive technology—caught my attention a few years ago while I was doing research at Boston Children’s Hospital, so I joined a team testing a particular bioresponsive software program to learn more. The way I work with kids hasn’t been the same since.

Not unlike biofeedback, bioresponsive tech monitors key body processes, taken by a heart rate monitor, to show users a connection between their body and mind. But what enables it to capture kids’ attention is the way it teaches the process of emotional regulation through engaging, interactive video games. By practicing these games, children, along with their families—who factor heavily in my therapeutic process—learn to improve self-regulation in a fun and accessible way. Another big plus: bioresponsive tech can be used on tablets and phones. Its portability means kids and families can get tutorials in their therapist’s office and further their gains at home, where the vast majority of triggers occur.

I like to think of bioresponsive games as a “program of practice,” rather than a treatment. Instead of relying on kids remembering complex cognitive techniques, they encourage automatic behavior through repetition. Kids who use these games learn self-regulation by practicing over and over again, like tying a shoelace or playing a musical instrument.

In my work, I’ve found that when kids learn about their body and how it responds to big emotions, like excitement, anger, frustration, or fear, they’re better equipped to control them. In essence, we’re creating a virtual safe space, where they can build emotional muscle memory that helps them respond to challenges in everyday life. It’s powerful to witness the relief and joy many kids feel when they develop this control and gain the ability to separate themselves from their emotions. This was the case with one memorable young client, Mark.

Mark and His Dragon

As part of the hospital research team and an adjunct clinician, I was sent to Mark’s school to test the effectiveness of the technology with children who were struggling behaviorally. His teachers and parents told me he regularly experienced outbursts and meltdowns, most often when it came time to do schoolwork. The administrators warned that if his behavior didn’t change, he might have to be held back a grade.

Nine years old, Mark was the youngest of four brothers, all of whom were successful in school, sports, and peer relationships. Mark was smart and compassionate, but he struggled with self-regulation skills, lashing out at teachers when classwork became difficult and fighting with peers when he felt frustrated. The more trouble he found himself in, the worse he felt about himself, and the more he believed he’d never measure up to his siblings. Sometimes his mother heard him mumbling under his breath, “I’m such a bad kid.”

Despite his self-criticisms, Mark was instantly likeable. I could tell he meant well and wanted to behave, but that he was hampered by his inability to control himself—which fed right into the “I’m bad” trap. “Why should I bother trying to do what they say?” he muttered in our first therapy session. “I always get in trouble anyway.”

Mark was convinced he’d always be the kid who lost his cool, but it was clear to me that he just needed a new strategy for handling emotional ups and downs. So my first goal was to have him focus on aspects of self-regulation he could see, externalize, and learn to master. “What kinds of things do you wish you could change?” I asked him. Surprisingly, Mark didn’t need any help coming up with a list: he wanted to have fewer verbal outbursts and be asked to leave the classroom less often, and he wanted to have fewer fights with classmates on the playground and with his siblings at home.

“That’s great, Mark,” I continued. “I’m trying out a new tool with a few kids here and I think it might help you accomplish some of those things on your list. Would you be willing to give it a try?” Mark nodded, and when I told him it involved playing video games and wearing a heart rate monitor, his face immediately lit up.

As Mark took a seat in my office and powered up an iPad connected to a heart rate monitor, I explained that when he got excited, frustrated, or angry, the Gizmo—a thermometer-like gauge on the screen—would glow red, and the game would get more difficult to play as little distractions appeared onscreen that would make it harder to focus. When this happened, he could pause the game, and a dragon would appear to instruct him on how to take slow, deep breaths, essentially allowing him to see and interact with his emotions. “To win, you need to try to keep your heart rate low by keeping your body and emotions calm, but it might take some practice,” I told him.

As Mark began playing, I could see him beginning to loosen up. Rather than try to engage him in conversation, I stayed quiet, watching as he took in the game. Soon, without prompting, he began to open up a bit about the things in his life that made him upset, like how he felt his brothers were “better kids” than him, and how he worried he’d never be able to please his parents and teachers. The game seemed to give him something to focus on, taking the pressure off the get-to-know-you phase of treatment, which can sometimes be difficult with children.

As he talked, however, Mark’s heart rate slowly rose, and he became visibly frustrated as the Gizmo began to light up, and the screen slowly began to fill with smoke. He grumbled under his breath, “This is too hard. This stupid thing isn’t working.” Mark’s shoulders tensed and his brow furrowed. “See?!” he exclaimed in exasperation. “I can never do anything right.”

“Mark, look at how high your heart rate gets when you’re frustrated,” I said. “Can you bring it down a little?”

“No!” he responded. “I just want to play, but these stupid games won’t let me!”

I tried to get Mark to focus on what the in-game cues were telling him about his heart rate. He had two options, I told him. One, he could try to play through it, even though he couldn’t see what was happening because of the smoke filling the screen. Or two, he could press the pause button, which would put the game on hold until he could bring his heart rate back down. He decided to press pause, and the dragon popped up on screen, instructing him to take slow, deep breaths.

“What’s that dragon telling you to do?” I asked him gently.

He still looked frustrated, but I could see his eyes following the instructions on the screen. Slowly, he relaxed his shoulders and took a few deep breaths, per the dragon’s prompting. The Gizmo’s red glow began subsiding. “That’s great, Mark!” I told him. “See? Your heart rate is dropping!”

“These games are stupid,” he said again, but with less force this time. Mark’s teachers and school counselors had tried for years to convince him to use various relaxation techniques to calm down, but it was a cartoon dragon in a video game he seemed most willing to listen to. Watching him interact with the dragon and find some self-regulation success was almost magical.

While it took some time and effort, over our next few sessions, Mark gradually became more aware of his heart rate and started learning how to control it. In each session, we set aside 15 minutes to play the game. While he played, I’d help him connect the visuals to how he was feeling in real life. For example, when the Gizmo lit up, I’d ask him if he was feeling excited, anxious, or frustrated. To expand this learning, we’d spend the rest of our sessions talking about how his schoolwork was coming along, or whether he felt he was meeting the behavior goals he’d set for himself, watching to see how the conversation was affecting his heart rate. Soon, he began to understand how his heart rate was a proxy for his emotions—and that his emotions were a part of him but not all of him. Together, we were creating a language for all this that he could apply to everyday life, using heart rate as a nonstigmatizing, easy to externalize foundation.

After four weeks, Mark was using breathing techniques to keep his heart rate down while playing the game without my assistance. Beyond my office, his teachers reported improvements in his schoolwork and classroom behavior. But I knew that for these changes to stick, we’d have to support therapy outside our sessions. The next step was getting Mark’s family involved.

Recruiting the Family

Once children understand what it feels like to be dysregulated and have a basic understanding of coping skills, I like to implement what I call a family self-regulation plan. This involves helping parents and siblings speak the new language the client has learned in therapy, including tying terms like low heart rate and high heart rate that we use frequently in treatment into everyday emotional life. Mark was making progress. But in our sessions together, he still occasionally referred to himself as a “bad kid.”

I called Mark’s mother, Sandy, to tell her about our work and my interest in involving the family. She was immediately on board. “I know Mark struggles,” she said. “But I see his strengths and want to do more to help him.” We agreed to meet one-on-one to discuss some strategies we could work on together.

Sandy came to my office later that week looking distraught. “Yesterday, Mark was in tears after he got mad and yelled at his brother,” she told me. “I could tell he was more upset with himself. It breaks my heart when he has these outbursts and then beats himself up. I just don’t know what to do.” Although Mark’s behavior had improved, his parents and siblings would be instrumental in changing his self-perception and improving his ability to incorporate the calming strategies he was learning into everyday life.

My first goal with Sandy was to help her externalize Mark’s behavior for him. I told her, “Sometimes people are more open to growth when they can identify specific aspects of themselves they want to change, rather than seeing themselves as fundamentally flawed. Have you ever noticed that when you talk about something as if it’s one degree removed from you, it takes away the sting?”

“I think so,” Sandy said, looking a little confused.

“For example,” I continued, “I’m a terrible cook. But it’s much more palatable for me to think of myself as someone who doesn’t do a great job cooking gourmet dinners than as a bad cook. Even though both statements are accurate, it’s easier to reflect on something I do badly than the idea that I am bad. The same is true for kids. Saying to Mark, ‘It’s not so good when you get frustrated and start yelling,’ is easier for him to swallow than ‘You’re a bad kid who yells.’ Mark is saying the latter about himself, and our challenge is to help him shift. One way to help him with this is to ask about his high heart rate instead of telling him to calm down when he gets frustrated. This way, you’ll be speaking a language he’s learning here with me, one that won’t inadvertently reinforce his negative feelings about himself. And if you and the whole family practice this language together, I think Mark will start seeing himself less as ‘the problem.’”

Sandy smiled. “I totally get it,” she said. “If someone tells me to calm down when I’m upset, it makes me nuts. Plus, we could all work on relaxing a little more!”

Over the next couple of weeks, Mark’s family began incorporating this language in daily conversation. During dinnertime, the family members even made a habit of sharing a moment from earlier in the day when their heart rate was “in the red” and what they did to lower it. Mark and his parents also came up with their own game, where they’d observe strangers and try to guess their heart rates. For example, one day at the grocery store, Mark said to his mom, “Look at that baby crying over there. What do you think his heart rate is? And how about his mama’s?” I was thrilled to learn that they were creating their own ways to expand our work and grow together.

Change in Action

Over time, Mark seemed happier and more confident, and reports of his misbehaving in school were few and far between. One day, toward the year of the school year, he ran over to me on the playground.

“Miss Erina, can I use that game to get my heart rate down?” he asked. “Billy hit me, and I’m afraid I’ll hit him back. I don’t want to get in trouble.”

“Sure, Mark, that’s a great idea,” I told him. We went inside, and after playing for several minutes, he calmed down.

“I feel better now,” he told me. “I’m ready to go back outside.”

About a week later, I got a call from Mark’s math teacher. She told me Mark had a particularly challenging moment in math class when he couldn’t understand an exercise. He looked as if he was about to have a meltdown, but instead of resorting to his old behaviors and disrupting the class, he started doing some deep breathing, as the dragon had been instructing to do in the game. “I spoke with his other teachers,” she added, “and we think Mark’s going to be able to join his classmates in the next grade.”

The next day, Mark greeted me by running into my office. “Guess what?! Guess what?!” he said. “These games—they’ve taught me that I can calm myself. I can fix myself. I don’t have to be a bad kid anymore! I can stay with the rest of my class!”

After six weeks together, my time at Mark’s school was up. But since then, I’ve heard through the grapevine that he’s still with his grade and is thriving at school and at home.

Behavioral change isn’t linear or easy. Once kids fall into a cycle of shame and failure, it can be difficult to pull them out. As therapists, we have myriad tools at our disposal, but it can be hard to find ones that allow us to meet kids where they are. Bioresponsive tech isn’t the only method for teaching self-regulation, but it works for me and the kids I treat. The fact that it provides visual cues, helps with externalization, encourages client independence, and helps create a language for family translation sets it apart from more mainstream—and often, less effective—methods. While my hope is that this technology will one day be as widely available to therapists who work with children as Legos and board games, my dream is that schools and families everywhere will also have access.

Case Commentary

By Ron Taffel

While I’ve used technology in my practice for nearly a decade, what stands out to me about this case is simple: this is excellent, nuanced therapy. The “rise of the machines” has been happening on many treatment fronts, but the way Erina White structures the relationship with Mark is so sound, it should be a teaching model for therapy with kids, teens, and young adults across all modalities. Why? Because this case is not just about tech; it’s about a deeply human experience, in which White creates change though something we too often underestimate in treatment—the magic of play.

White describes how, before we turn to the dragon and Gizmo in the video game, we need to create a safe space and shared treatment goals. As Mark shows, he has ideas about what would make a difference to him. Only after creating this working alliance does White introduce the biotech video game, at which point Mark’s face lights up. Not surprisingly, the idea that therapy will include fun is a game changer. He relaxes, loosens up, and starts, as almost all kids and many adults do through play, to talk about his life.

In addition, talking to clients about dysregulated emotions or most shame-laced behavioral problems is where difficulty often arises in therapy, and where White’s use of technology is particularly creative: the video game, and especially the dragon, create an ongoing metaphor, a nonblaming way to practice emotional regulation. The metaphor begins with a concrete heart rate, allowing them to reframe and externalize the presenting problem.

Although we don’t talk about it enough clinically, most therapists naturally play off their clients’ interests. It’s something you can do with almost every client, with or without a Gizmo. Whether you discuss, joke about, or debate TV, music, sports, celebrities, or politics, you’ll discover a shared metaphor to talk through. And just as White describes, over time this becomes a special connection; you’ve created your own unique language together.

Much the way Mark listened to the video cartoon more easily than to anyone else, clients of all ages can better address their emotions through play and metaphor. For example, I might say, “Wow, we really get heated up arguing about which Avengers movie is the best. Are you having an Avenger moment right now talking about your brother?” Playing with the metaphor externalizes painful issues so they can be owned. You can say almost anything and be heard when it’s within a metaphor attuned to your client’s interests.

But White goes on to do something too many therapists brush aside: she brings the central metaphor into the family. This is critical even when working with young adults. In her straightforward way, White invites mom into the therapy metaphor by playfully revealing her own cooking issues while teaching a more palatable way to reflect on our deficiencies. Mom then understands that the family needs to rename Mark’s issue, and gradually the whole family begins to expand the heart-rate metaphor at home.

Rather than inadvertently creating wounds, they were able to name dysregulated emotions together and have fun at the same time. White planted a seed that bloomed beyond the treatment room, circled its way around their dinner table, and then into his wider life. But fear not if you don’t have access to the biotech that White uses, because as she demonstrates: you—or more precisely, your attunement—can be the Gizmo. While we can’t guarantee accurate tracking of heart rates, good therapists have a nuanced read of the slightest emotional shifts in themselves and their clients. What they do with this information is a more complex matter.

Ultimately, White introduces a well-thought-out and an increasingly sought-after way to approach emotional dysregulation and other behavioral disorders through integrating technology, clinical attunement, and the magic of play.


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Erina White

Erina White, Ph.D., MPH, MSW, is the clinical services director and vice president of parent services for Mightier, a bioresponsive technology program.  She’s a clinical researcher at Boston Children’s Hospital and a therapist in private practice, and holds faculty appointments at Harvard Medical School, the University of New Hampshire, and Simmons School of Social Work.


Ron Taffel

Ron Taffel, PhD, is Chair, Institute for Contemporary Psychotherapy in NYC, the author of eight books and over 100 articles on therapy and family life.